Game turns smartphones into teaching tools for doctors

The day after returning home from a Key West vacation, a 25-year-old man develops malaise, fever, and a headache. The day after that, he comes down with a rash. Which of the following is the most likely diagnosis: enterovirus? measles? rubella? dengue? Rocky Mountain spotted fever?

After they graduate from medical school, new doctors spend the next several years patrolling hospital wards, learning how to answer these kinds of questions as quickly as possible. (In the scenario above, the answer is dengue.) Attending physicians oversee the residents’ work, and are responsible for their continuing education; senior-level residents pass on wisdom on the art of doctoring as well. Gone are the structured exams of medical school. Apart from an occasional pop quiz during daily rounds, the accumulated lessons from one patient encounter have to be stored away in memory until they are needed, perhaps years later.

Angry Docs

But a new game making the rounds at the UAB School of Medicine gives internal medicine residents an immediate chance to make use of their newfound know-how—and earn some serious bragging rights. For the past year, students at the School of Medicine’s campuses in Birmingham and Huntsville have been answering daily questions as part of a Web-based gaming platform called Kaizen.

The home-grown, mobile-optimized system puts UAB at the forefront of a hot educational trend: “gamification.” Gamification has four key elements, says James Willig, M.D., a UAB infectious diseases physician who founded the Kaizen project along with Martin Rodriguez, M.D., a colleague in the Division of Infectious Diseases. “It must include a clearly defined outcome players can work to achieve, rules, a feedback system so players can track progress, and voluntary participation.”

Kaizen, named for a Japanese term that translates roughly as “continuous improvement,” uses all four elements. When Willig was a medical resident in the 1990s, he spent his precious downtime glued to his Palm Pilot, playing Snake, the hottest—and virtually only—mobile game of its era. Today, when every med student’s white coat holds an Internet-connected smartphone, Facebook seems to be the off-hours diversion of choice. But Willig sees plenty of educational potential in all those iPhones and Androids. His vision: Take the same techniques that make people addicted to Angry Birds and use them to produce better doctors.

Kaizen’s goal isn’t to stump docs-in-training—or peddle in-app purchases. After players choose a response, they get a detailed explanation of the correct answer. It’s a teaching experience disguised as a rapid-fire quiz, with questions designed to reinforce the major lessons a doctor needs to know—and introduce the latest thinking in the field.

“The game absolutely helps your medical skills,” says second-year resident Matt Skinner, M.D. The questions are typically focused on either recent updates to medical guidelines or on the “zebras” of internal medicine, he notes—the kind of cases a physician may only encounter once or twice during a career. “But there are a lot of people on the planet, so rare diagnoses pop up every day,” Skinner says. “The aim is to make sure that you are the physician who makes the diagnosis when it appears.”

“I had a patient with a rare medical condition on my clinical service, and the next day his diagnosis came up in a Kaizen question,” says first-year resident Jori May, M.D. (pictured below). Needless to say, she got the question right. “It’s a great reinforcement of clinical scenarios, both common and rare, that we see on the wards.”

Rush Hours

Willig’s high-tech quiz has its roots in a tectonic shift in the way doctors are trained in the United States. In 2003, the Accreditation Council for Graduate Medical Education passed a new rule limiting the number of hours that residents could work, from an essentially unlimited number to 80 hours per week. In 2011, the rules changed again, limiting first-year residents to no more than 16 hours of work in a row.

“I think the new work hours are a great idea, because when I trained I worked 40 hours straight and I know I did not do as good a job in hour 40 as I could do in hour one,” Willig says. But fewer work hours also mean fewer opportunities for experienced doctors to pass on lessons to the next generation, he notes.

In 2012, with a grant from the UAB Health System’s Innovation Board, Willig conducted focus groups with upper-level medical residents at UAB and documented a common refrain—everyone felt that teaching opportunities were being lost. It was clear that, “to adapt to the new realities of medical education, we have to teach in a different way,” Willig says. “So we decided to take advantage of the online environment and build a nice, competitive community to help students learn.”

Willig and a group of colleagues that include Martin Rodriguez, Donald Dempsey, medical student Christa Nevin, Mukesh Patel, M.D., and Andrea Cherrington, M.D., quizzed chief residents around UAB Hospital, asking them to “identify great teachers,” Willig says. Then they asked those physicians for the “10 things you make a point of trying to teach a resident when they rotate with you.”

The Aerodynamics of Teaching

There is an art to crafting successful questions, Willig notes. Providing a clear explanation of why the right answer is right—the meat of the teaching—is crucial. “But a great question is also aerodynamic,” he says. “It gets to the point” so as to fit into the harried life of a resident. “I should be able to start reading it as I get on an elevator and finish by the time I get off,” Willig says. “And if you can make it funny, that’s a bonus.”

Like commercial software developers, the UAB team regularly mines its player data to figure out how, why, and when players play—as with any educational endeavor, making students want to learn is the most important step.

“There’s a growing interest in gamification in medical education, but not a lot of research,” Willig says. The Kaizen team was particularly interested in the best ways to reduce “churn”—losing players over the course of the game.

They wanted to know whether awarding virtual “badges” for good play would increase motivation, for instance. It did, but the online leaderboard was an even more powerful motivator. And the players themselves suggested a successful refinement. Giving them the option of forming teams increased playing time—presumably because of the social rewards and pressures that added to the mix.

“The team aspect of the game is great,” says Skinner, who has been playing Kaizen throughout his UAB residency so far. “It’s been nice to see the pseudo-rivalries develop. I think it plays to the natural competitive streak that most of us have.”

Let Me Ask You a Few Thousand Questions

After a successful launch at the School of Medicine’s Birmingham campus in fall 2012, Robert Centor, M.D., dean of the school’s campus in Huntsville, got wind of the game. “Docs being docs, he wanted his residents to get in” on the competition to prove their mettle, Willig says. In the months since, the team has received interest from other U.S. medical schools and as far away as Peru.

In the first three rounds, run between August 2012 and May 2013, students answered a total of 16,427 questions. “That is 16,427 teaching interactions that would not have otherwise occurred,” Willig says. “I wonder if I’ll reach that number of personal teaching interactions in my entire career.” Follow-up testing showed a 10 percent increase in retention of knowledge six months after initial exposure to the questions. It also revealed some stats that surprised the Kaizen team.

Never Stop Learning

Now, a project that Willig describes as “run on the kindness-of-strangers model—all scotch tape, string, favors, and good will,” has earned a major investment from the UA Health Services Foundation’s General Endowment Fund. With a grant for more than $150,000, the Kaizen team is purchasing equipment and the technical support they need to take Kaizen to new heights, including the ability to run multiple games simultaneously and add participants from other schools and other UAB departments. Surgery (led by Jared White, M.D.), ob/gyn (led by Alice Goepfert, M.D.), and the internal medicine clerkship (led by Nicholas Van Wagoner, M.D.) are already playing.

Kaizen has the potential to expand beyond residency programs into continuing medical education for practicing physicians as well. Board-certified physicians like himself must take a test every 10 years to keep their certification, Willig explains. “We have this traditional cycle where we get knowledge and then weeks, months, or even years later, we get an exam. That’s a very slow loop of test feedback. Kaizen gives it to you in a steady stream.”

Senior resident Adam Edwards, M.D., who has been playing since the first season in fall 2012, says he will likely continue to participate even after his residency is over. “I think it is well worth the brief amount of time invested because of the concentrated return on that effort,” he says.

Kaizen isn’t intended to replace face-to-face teaching—just enhance it, Willig says. “You’ve got to keep working on your ignorance every day,” he says. “The doctor you are three weeks from now should be better than the one you are today.”